Innovation summary

A recent situational analysis conducted in Kashmir indicated that there was a centralized mental health care system in place, marked by poor treatment standards, lack of mental health drugs and lack of knowledge in health professionals to appropriately diagnosis mental health problems.

This innovation seeks to use the World Health Organization's mhGAP framework to train health professionals from diverse specialties to reduce the treatment gap found in Kashmir and eventually decentralize the current mental health system. The training program uses WHO validated tools to train as well as to monitor and evaluate the effectiveness of the program in reducing the treatment gap. Two preliminary short trainings have been conducted and a year-long pilot is currently taking place in the Ganderbal District.

Impact summary

110 health professionals trained in two weeks of preliminary training

Planned evaluation to take place after pilot program is completed

“Enormous efforts had gone into [this mhGAP initiative in Kashmir], this I know for sure, as I am trying to setup 2 mhGap trainings in India, without much success so far”

-Dr Mina Bobdey, a mhGAP Trainer in Kashmir1

The main image is a submission by Masood Hussain, a renowned Kashmiri artist. It depicts a praying woman's face and hands peeping through a lattice window - a symbolic image intertwined with the success of the project.

Innovation details

The World Health Organization's Mental Health Gap Action Programme (mhGAP) has been developed with the aims of training and capacity building in order to deliver services for people with mental, neurological and substance use disorders for countries especially with low and middle income. According to the WHO “Mental, neurological and substance use disorders are common in all regions of the world, affecting every community and age groups across all income countries. While 14% of the global burden of disease is attributed to these disorders, most of the people affected -75% in many low-income countries- do not have access to the treatment they need”.

Kashmir has been going through conflict since 1947 and in the last 25 years there has been armed conflict which has led to many fold increase in mental disorders. Conflict is ongoing and people continue to suffer, with limited access to mental health services. There is only one psychiatric hospital based in capital Srinagar with 25 to 30 psychiatrists for the whole population of Kashmir valley (approximately 800,000 people). Given the system is very centralized, there are not any psychiatric services at the primary care level and there is very limited access to psychiatrists at the district level.

District Mental Health Program

Objectives

The District Mental Health Program, part of the National Mental Health Program, is the flagship program for mental health intervention in India. It is the first initiative to move away from institutionalization to community care by collaborative arrangement with strong community participation, linkages with voluntary sector and civil society initiatives,with academic institutions from inter disciplinary backgrounds and use of private sector knowledge and skill base with adequate safeguards against commercial interests prevailing over public interests.

The overall objectives are:

To deliver a standardized mhGAP training to prescribers and non-prescribers working in primary care settings in Kashmir

To increase participants’ confidence and skills in the assessment, diagnosis and management of the priority conditions prioritized by mhGAP

To increase participants’ skills in a range of training techniques, facilitators and supervision skills, identifying a pool of local mhGAP champions

To raise the profile of mental healthcare among primary care workers

The innovation works alongside the District Mental Health Program to use a decentralized community based approach to the problem by:

Training the mental health team at the identified nodal institutes within the state

Providing adequate services to promote early detection and treatment of mental illness in the community itself with both outpatient and indoor treatment and appropriate follow up measures

Collecting data and experience for future planning, research and improving service provision

Further it seeks to take the mhGAP training program one step further by evaluating the training. This element is an innovative feature, one that other mhGAP programs do not usually include.

3 Phases of Training in Kashmir

To date there have been 3 phases of training in Kashmir as part of this innovation, supported by the Director of Health Kashmir:

Preliminary Primary Care Training (September 2013)

A two-week preliminary primary care training was conducted for 120 health professionals from all over Kashmir in September 2013. The training was delivered by a team of UK, Kashmiri and Dutch psychiatrists and psychologists who were recruited from the Royal College of Psychiatrists Volunteering and International Psychiatry Special Interest Group.

Secondary Care Training (August 2014)

The second phase was coordinated by the secondary care level to link primary and secondary levels of care effectively. This phase included new participants from secondary care and from the private sector. The training specifically focused on the child development modules of the mhGAP.

Pilot Program in Ganderbal District (August 2014)

Following a series of meetings over 2013-2014, a steering group was formed for development and implementation of the pilot project in the Ganderbal district. This steering group was essential in preparing an extensive background sketch for the implementation of the pilot.

Training was repeated in August 2014 and focused on primary care physicians in Ganderbal district. The meeting was held with the Chief Medical Officer, the Block Medical Officer and medical officers of the Ganderbal district to establish a robust supervision, monitoring and evaluation system over the following year as per supervision and monitoring framework. The BMO and MO were identified as supervisors.

The objectives of the pilot training program were:

To train all GPs in the Ganderbal district of Kashmir (India) in mhGAP implementation guide tool

To implement the mhGAP based integrated mental health primary care service in Ganderbal

To implement a supervision framework for 1 year for GPs in Ganderbal

Key drivers

Support from Key Partners

Support from the health department has been essential for the innovation for implementation and incorporation into the District Mental Health program

Challenges

Lack of Human Resources

The structure of the innovation depends on one lead employee, who works with volunteers, to support the trainings and implementation of program. For further successful implementation, it will be key to increase the number of people working on this initiative.

Gathering Data for Monitoring and Evaluation

Gathering data required for M&E will be a challenge as patient records are not well kept and patients often see different GPs. Patients also may visit traditional healers or other doctors, again contributing to gaping holes in their medical records.

Continuation

If the evaluation proves that the innovation is effective, the program will be rolled out to other districts in Kashmir.

Evaluation methods

The study will monitor all GP practices in Ganderbal with a specific intervention of mhGAP program.

Study Design

The study design is a quasi-experimental design. Given that the innovation takes place in a real world situation, there are many confounders that cannot be controlled for. The baseline data will serve as the comparison, as the logistics of a sample from another area are too complex for this study. The baseline data will be compared to the data collected from 3, 6, 9 and 12 month checkups in the district.

The study is a prospective study beginning at the end of 2014 and continuing on for 1 year.

Monitoring and Audit Systems

A monitoring system will be implemented through the WHO toolkit. Data that will be collected will include the number of cases seen, drug prescriptions prescribed and the number of cases seen for follow up. A health information systems program that is used at the Primary Healthcare level will record the diagnostic category, which will also be monitored through the WHO toolkit.

The audit system will measure practice against the standard of mhGAP protocols. This will be done through supervision using the monitoring and evaluation component of the WHO toolkit. Interventions at PHC level will be recorded according to module standard and can be quantified and audited as appropriate. In addition, the supervisor will directly observe the practitioners and evaluate whether they able to assess, diagnose and manage cases according to an appropriate standard. If issues are detected, an intervention will be developed to ensure good quality of care.

Evaluation Indicators

A sample of the indicators the innovation will be measuring:

Number of prescriptions – GPs will record the number of prescriptions they prescribe. Indirect indicator might be the prescribing of vitamin tablets and injections which is very common in Kashmir. With mhGAP model one would expect a decrease of such prescribing.

Quality indicator – Patients will be asked their satisfaction with the innovation. The Verona Service Satisfaction scale from the EPSILON study will be used.2 This scale has not been used in Kashmir and would need an adaptation.

A complete list of indicators for mhGAP can be found in the resource section.

Cost of implementation

Total project costs: $88,636 (USD). A cost analysis has not been conducted.

Associates

Comments

This Innovative mhGAP project has been initiated, designed ,and implemented by myself and was submitted as innovative project under my name. All the work done in this project so far with support from Kashmir Government, WHO Geneva and Royal college of Psychiatry has been entirely coordinated by me and the implementation and evaluation phase is also entirely coordinated by myself. I am the only associate who is responsible for coordinating it at ground level.

Feedback by one of the medical students who is part of online innovative interactive workshop between medical students of Kashmir medical college and UK medical students on mhGAP who also attended the mhGAP training session in Ganderbal where the monitoring and implementation phase of mhGAP is being implemented in collaboration with Royal College of Psychiatry London, Government of Jammu and Kashmir with support from WHO Geneva
"Thank you sir for taking us along and being so patient with us.Today was even more productive than the last time.We covered three modules and also had a revision of the previous session, and (my friend) was telling me she enjoyed a lot and she was actually considering psychiatry now:) It was a great experienced and I learned a lot.What I like about mhGAP the most is that its very practical and easy to implement!"

.Respected All
You would be pleased to know that by the Grace of God we successfully completed the first online supervision of mhGAP trained doctors of District Ganderbal at Govt Medical College Library
Doctors from more than 21 primary care centres attended the supervision session and received online supervision from more than 10 UK and Dutch based consultants using the online supervision site of Kings College London.
The supervisors were impressed by the enthusiasm of the doctors and the quality of cases presented by the doctors.
The mhGAP team were thankful to Principal Medical College who gave permission to use the library at the request of Director Health services Kashmir.
Todays supervision completed the monitoring and supervision component of the mhGAP project in Ganderbal
Wasalam and Regards Aqeel
.

Dear Sayed
Many congratulations - you have been shortlisted in the RCPsych Awards 2015, in the category Psychiatrist Volunteer of the Year.
The shortlists can be seen in full on our website at www.rcpsych.ac.uk/awards2015
I am pleased to invite you and a guest to attend the RCPsych Awards Ceremony on 10 November 2015, when the winners in each category will be announced. Tickets are free of charge.
Date Tuesday, 10 November 2015
Venue The Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB
Liz Cowan
Communications and Marketing Manager

Thank God we have successfully managed to complete the monitoring and evaluation project of mhGAP at District Ganderbal. The results ,data along with recommendations have been submitted to the Royal college of Psychiatrists London .The results will be presented at the WHO 7th mhGAP forum in Geneva God willing by me and Dr Muzaffar and formal report with recommendations will be submitted to the Kashmir Government by the President of the Royal College like last year.
I am highly thankful to all the doctors of District Ganderbal who worked with zeal and enthusiasm to make this project a success the recommendations of which will be implemented across the world

Thank God we completed the on line Interactive session between the medical students of UK and medical students of Government Medical College Srinagar where by the students discussed the chapters of mhGAP Interactive Guide using the online interactive site devised by Kings College London

workshop cum commemoration of the “World Suicide Prevention Day” at Srinagar
Current News Service (CNS)
“World Suicide Prevention Day”Srinagar,September,10,2015-CNS:-a Holistic Healthcare Initiative working under the aegis of HELP Foundation J&K today held a workshop cum commemoration of the “World Suicide Prevention Day” at its Hyderpora office. The day was marked with a discussion and brainstorming session among the various representatives of prominent ngos like Unicef, Actionaid, CRDP, Borderless world foundation, HPVT, Drug de-addiction centre, SOS children villages, Childline 1098.
Besides few Advocates, Consultant Psychiatrists, Media personnel, and Religious Scholars participated in the workshop and shed light on the issue. In this workshop the suicide issue in Kashmir was discussed threadbare and efforts were made to formulate the strategies to address the same. Considering the alarming trend in suicide rate in Kashmir, the workshop attempted at putting this discourse before public and channelizing the resources for developing the preventive strategies to deal with same.
Few experts like Dr. Aqeel Hussain shared the WHO report on suicide as he was a part of it when it was made open to public and Advocate Mohd. Altaf Khan shared the legal aspects and perspectives on the same. Dr. Mohd. Muzafer Khan- Director Drug de-addiction centre also shed light on the pattern of Suicidal ideations and drug addiction. Apart from this, Dr. Suhail Masoodi- Director CRDP, Mr. Hilal Bhat- Unicef representative, Mr. Nazir Ganai – Rising Kashmir Editor, Mr. Tanveer Ahmad- Coordinator Action aid, Dr. Shabir- Medical Officer PCR, and Mr. M.D. Ronga- HPVT representative also shared their views regarding the prevention of problem of Suicides in Kashmir.
The focus was put on
To put efforts in drafting an authentic research base in order to carry out studies and intervention in the same area.
To promote advocacy for suicide prevention with Govt. bodies particularly Police dept. at par with the standards set by the international community.
Building up strong networks with mental health institutions to deal with the issue of suicide & its cause & effect relationship at individual and institutional level.
Implement the modalities and strategies at the basic school level.
Incorporation of the various Life-Skills at the elementary level to supplement the prevention strategies regarding Suicide.
Ensuring the follow-up of suicidal attempted cases after being reported and dealt with the relevant medical intervention.
Consideration and revisiting the legal aspects of suicide and its implications.
Sensitizing the communities and civil society to deal with the issue of suicide at the grass-root level.

Was Humbled by the compliment of Prof Yousuf Ex Head of Medicine GMC Srinagar at CRDP function at kashmir University .Professor Yousuf had attended the full 5 days of mhGAP Training in collaboration with Directorate of Health Services Kashmir, Royal College of Psychiatry and support by WHO.
Regarding the training Prof Yousuf said that it was because of that training he has added a full chapter on mental health to the next edition of his book Emergency Medicine.

Alhamdulillah
We have managed to successfully complete the online interactive project.I on behalf of Royal College of. Psychiatry and WHO am thankful to final year and prefinal students of Gmc Srinagar who despite their busy schedule actively participated in the project and made it a success.
I am also thankful to members of this group who provided valuable support.
Certificates on behalf of Medical college Srinagar, Royal College of. Psychiatry and WHO will be given after 10th of September
Am sharing feedback of one of the student
Asalamualaikum Sir. I mostly had only postive experience from the experience. Firstly, it was good to talk to your peers from a developed country and compare our lives, ways of studying, patient interaction etc. It was a novel experience to know how much the developed countries are different from us, not only in infrastructure but in various ways. The problems we had in our countries were different, family set up, cultural diversity. It was good to come across different opinions. In psychiatry, it was great to know about a single disease from differing perspectives. Of similar diseases in contrasting backgrounds. How administration of a developed countries takes over the role of the family, and how much dependent the developing countries were on social contacts. Also the stigma and awareness of different diseases in our countries. I think I got a lot of exposure from doing this project. Even the minor things had so many significance when we compare them in our countries.
I also knew more about the diseases and their approach to diagnosis. Lastly, I made a good friend who was always polite .I never had any issues related to the time difference. Net connectivity was initially poor due to the floods. Rest we managed and I am really glad that I did.
Future Recommendations : improving the method of communication, the site had some issues when the speed was slow and with different browsers.
Making pairs on the basis of matching times of being available.
Rest it was great!
Thanks a lot for giving us this opportunity!

Had an excellent WEBINAR session which was supported by mental health worldwide, and in2 mental health. I am grateful to MHIN for supporting the webinar session which will be uploaded on the page once it is converted into u tube format .
More than 65 participants had registered from all over the world .It was attended by Professors, representatives of IMC pakistan , iraq ,uk and other countries.The feedback about the session was excellent.I hope people will be able to use it in developing mhGAP related work across the world.

The webinar videos have been completd and mad into two parts .They have been submitted to the MHIN team as requested by them and will be uploaded God Willing on the mhGAP page of MHIN soon.
look out for the videos

One Day Psychological First Aid workshop was conducted by myself and Dr Mohammad Muzaffar Khan at Centre for Mental Health Services Kashmir under the aegis of HELP Foundation using the WHO Formulated Psychological First Aid Module.
The module was held in collaboration with Directorate of Health Services Kashmir and supported by WHO Geneva.
The significance of Psychological First Aid is evident by the fact that this years Mental Health theme is Psychological First Aid .
it is worth mentioning that I got Psychological First Aid incorporated into the MOU signed between the Health and Medical Education Department of Jammu and Kashmir and RCPsych on the recommendation of Dr Shekhar Saxena Director WHO Mental Health and substance misuse and head of mhGAP in the world .
Dr Saxena was also responsible supervising the formulation of Psychological First Aid by WHO and is responsible for implementing the 2013-2020 WHO Global Mental Health Action Plan around the world.
The training was attended by nearly 50 participants from diverse professionals which included representatives of various NGOs ,doctors, psychologists,social workers and other allied professionals and more than 30 are on waiting list for the next training. We appreciated the enthusiasm of the participants who managed to reach the venue despite lack of transport due to restrictions.
The training was also attended by deputy head of red cross of south asia division as well as all members of the MSF besides members of all reputed organisations working on ground to help people effected by current political turmoil.
The recommendations and report of the workshop will be submitted to WHO during the psychlogical first aid workshop review session at the WHO headquarters Geneva on 10th and 11 october which will be attended by myself on the invitation of Dr Shekhar Saxena.
.
The participants appreciated the relevance of training in the current political turmoil and requested more trainings to be conducted which will be conducted by HELP Foundation in collaboration with Directorate of Health Services kashmir and suppported by WHO.
I would like to offer my thanks to Mrs Nighat Shafi chairperson of Help Foundation for providing excellent logistic support in the current turmoil without which it would not have been possible to conduct the training.
I am also thankful to Dr saleem ur Rehman Director Health Services Kashmir patron of mHGAP in Kashmir for supporting this workshop.
My special thanks to Dr Shekhar Saxena and his team for providing technical support and placing complete trust in me and Dr Muzaffar for conducting the training on behalf of WHO.
We hope the training will be helpful in the current political turmoil in addressing the physical, emotional and psychological needs of the people of kashmir.

WORD OF THANKS
With a debt of gratitude which cannot be adequately expressed in words, I firstly thank Almighty Allah and after that my supervisors especially Dr. Sayed Aqeel Hussain (Consultant Psychiatrist & mhGAP international Coordinator) and Dr. Mohammad Muzaffar Khan (Director drug De-addiction and Rehabilitation Center Police Control Room Srinagar & State Coordinator of mhGAP) for their godly influence upon my life, and for inspiring me to stand up for what is right. I have enjoyed working for mhGAP and I appreciate having had this wonderful opportunity to work with you all. During this working period you all have provided me support, and through your encouragement and guidance I have been able to excel at the projects offered to me. I enjoyed being taught by you immensely; you are excellent supervisors and have inspired me to continue learning with an open and positive mind. I appreciate all your hard work, it’s meant so much to me. The idea and project you carried out was a great success and really deserves all our appreciation and support.
In 2008, WHO launched the Mental Health Gap Action Programme (mhGAP) to address the lack of care, especially in low- and middle-income countries, for people suffering from mental, neurological, and substance use disorders. Fourteen per cent of the global burden of disease is attributable to these disorders and almost three quarters of this burden occurs in low- and middle-income countries. The resources available in countries are insufficient – the vast majority of countries allocate less than 2% of their health budgets to mental health leading to a treatment gap of more than 75% in many low- and middle-income countries. Health systems around the world face enormous challenges in delivering care and protecting the human rights of people with mental, neurological and substance use disorders. The resources available are insufficient, inequitably distributed and inefficiently used. As a result, a large majority of people with these disorders receive no care at all.
We work in collaboration with Royal College of Psychiatrists London and Health and Medical department of Jammu and Kashmir. In this regard we appreciate our administrative supporters, and are also very thankful to them who gave us the unique working environment. In this regard we are eternally very thankful to President of Royal College of Psychiatrists London (Sir Simon Wessely), Commissioner Secretary to Govt. Health and Medical Department of Jammu and Kashmir, Director Health Services Kashmir, CMO (Chief Medical Officer) Ganderbal, all BMO’s (Block Medical Officers) of District Ganderbal and finally our team of Doctors, Psychologists, Social Workers and Nurses who where the part of this project and training programme..
In addition to the above, the word of thanks also goes to more than 10 Psychiatrists from London who came to conduct mhGAP training in Kashmir and were regularly supervising our team of Doctors, Psychologists and Social Workers through online facilities. It was our hard and adventurous work by which mhGAP Kashmir Project is nominated as Best in the whole World. We hope that our project will be circulated in all districts of Kashmir. Finally I would like to congratulate Dr. Sayed Aqeel Hussain for the award of Psychiatrist Volunteer of the year in RCPsych awards 2015.
As we all are aware of the fact that large portion of population of Kashmir is suffering from different chronic mental illnesses particularly Depression, PTSD (Post Traumatic stress Disorder), Anxiety Disorders and other Psychotic and Personality Disorders, and there are not sufficient facilities available for identifying and constantly treating them. I hope our efforts will (to some extent) overcome these problems. As a Psychologist, Social Worker and Researcher in Mental Health, I would like to appreciate all those organizations, NGO’s and other Health Care Institutions that are constantly working for Mental Health in Kashmir and are involved in finding the ways of identifying, treatment and prevention of mental disorders in people suffering from different mental illnesses in the valley of Kashmir.
Syed Owais Shah: Clinical Psychologist as well as Junior Research Fellow (Mental Health GAP Kashmir), Kashmir_UK mhGAP Partnership.

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